Healthcare Provider Details

I. General information

NPI: 1861587024
Provider Name (Legal Business Name): JUDITH KATHRYN GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH KATHRYN GAVIGAN APRN

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 HOPMEADOW ST SUITE # 100
WEATOGUE CT
06089-9782
US

IV. Provider business mailing address

10 SACHEMS TRL PO BOX 383
WEST SIMSBURY CT
06092-2525
US

V. Phone/Fax

Practice location:
  • Phone: 860-658-0465
  • Fax:
Mailing address:
  • Phone: 860-651-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number002331
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: